PROJECT SUMMARY In the United States, 141 million emergency department (ED) visits occur annually, accounting for 11% of ambulatory care visits. While ED visits are characterized by high acuity, up to 25% of patients visiting EDs view it as their usual source of care. In addition, EDs serve a disproportionate share of low-income and uninsured patients, for whom high quality care during ED discharges may rest in meaningfully assessing and addressing the many social characteristics associated with poorer health outcomes such as homelessness, financial struggle, lack of insurance, and lack of routine care. By developing effective, sustainable methods for integrating both ?social needs? assessment and referrals into routine ED service delivery, this proposal will provide the necessary structure to deliver high quality care and reduce costs. In our preliminary work, we successfully piloted a social needs assessment and community-based referral process in the ED that leverages and links existing Health Information Technology and a robust community-based referral network. The objective of this study is to expand on this work by implementing universal social needs assessment during routine ED care, evaluating its potential to facilitate understanding of whether and how addressing social needs during routine clinical contributes to improved population health. The aims of this study are to 1) evaluate the technical and operational feasibility and acceptability of implementing a Health Information Technology-delivered social needs assessment and referral process during routine ED service delivery; and 2) obtain preliminary estimates of effectiveness of Health Information Technology integration of social needs and community-based referral data within the health system. Using a mixed-methods implementation design, we will work with our already-assembled workgroup of clinicians, community-based stakeholders, and consultants to integrate our social needs assessment into clinical workflow, directly refer patients with social needs to United Way of Salt Lake's 211 referral system, and integrate screening and referral information collected in the 211 ServicePoint database with clinical outcomes data extracted from Epic. All data will be reported back to the health system for population health planning. During this year-long test of the social needs assessment and referral process, we will rigorously evaluate usage of the 211 service by patients discharged from the ED; patient and clinician time and perceptions; and the effectiveness of linking social needs assessment, community-based referrals with health outcomes data (ED revisits, inpatient admissions and PCP visits within 60 days, of index ED discharge). Results of this study will provide health systems additional information about factors placing patients at risk for poor outcomes after ED discharge, and identify whether Health Information Technology can effectively integrate social needs assessment into routine health service delivery.